Monday, August 25, 2008

A good friend of mine has cancer. We went to school together. At 43 the ovarian cancer we thought she was winning against a few years ago has now spread to her bowels. At 43 I am trying to have an IVF baby. The whole IVF idea was one she conceived at lunch in my backyard prior to her illness. I said I would try if she promised to be in delivery room. It was a deal.

Now we are both struggling to keep the deal. I need to hurry up and fall pregnant and she needs to slow down and make sure she is around.

We have both seen many doctors in the last year. We have both long lost our dignity and surrendered ourselves to medical examinations that are sometimes painful and that we wouldn’t wish on anyone else. We have both learned many lessons about being a patient and about being a doctor. Here are a few:

Being a patient

• Know your body as best as your can and if you don’t know it - start to know it. For an IVF patient that means you need to write everything down, dates of your period, characteristics of your period, dates you starting taking vitamins, dates you went to acupuncture or yoga. Write it down and see if there is any pattern. Write it down so you can be a better patient.• Read as at least one bit of relevant material. There are many websites that promise that I can conceive easily and my friend’s cancer will go into remission … if we subscribe. Read critically.• Consider taking vitamins and adopting alternative practices that will make you healthier and will support you on your journey. Decide what your regime is and stick to it (and of course write it down).• Learn about the top 3 blood tests that will be performed on you routinely. Why are they done and what do they mean? If you have a supportive general practitioner, you may want to consider getting your top 3 blood tests done on a monthly basis. It will increase your knowledge of your body.• If you don’t like your IVF doctor, be brave and change doctors (I know it is difficult).• Build up your karma bank, not for yourself, but for your child.• Manage your expectations. • Be open to options, for example, the egg donor option. If you love your partner or husband you will be able to overcome this mental obstacle. Appreciate that there are different parts to being a mother, a genetic mother, biological and social mother. You will be the child’s biological and social mother and anyway children aren’t ours to own or control. We have them to nurture and guide and enjoy, all the time respecting that they are individuals.

Being a doctor

• We are in your hands. We know you can do the job because you are where you are. Use your emotional intelligence in dealing with us and not only your general IQ.• We carry your every word. We analyze it, discuss it with our friends. We carry it all day. It affects us. A glib response or a defeatist attitude from you reverberates through our community. • We will judge you on your emotional intelligence before we consider your IQ.

Saturday, August 23, 2008

Globalisation and health care | Operating profit | Economist.com: "What is more, there are good reasons for thinking that medical tourism will help poor countries. For one thing, private hospitals did not cause the state sector’s neglect of the poorest. Long before medical tourism or private hospitals took off, the state-run hospitals of India and most other developing countries were a shambles. This was chiefly the result of bureaucratic incompetence and corruption, not poverty—as the decent health-care systems in other developing countries like Costa Rica, Malaysia and even Cuba make clear.

Besides, the rising standards at private facilities promise to have important knock-on effects that may benefit even the poor. The World Bank has observed that the rise of high-quality private clinics in Trinidad and other parts of the Caribbean, for example, has encouraged highly educated doctors to return home."

Medical tourism promises to be what Aetna’s Dr Cutler calls “a disruptive market force that improves cost and quality here in America.” Whether or not it turns out to be all its boosters wish for, it will be a force to be reckoned with."

Monday, August 18, 2008

Using Technology for getting Informed Consent - The Informed Patient - WSJ.com: "The Department of Veteran's Affairs, with 153 hospitals, has over the past several years adopted a new electronic informed-consent software program that allows patients to use a digital pad to sign the consent forms, which can then be stored in their medical record. The program, known as iMedConsent, includes a library of anatomical diagrams and explanations written at a sixth-grade reading level for more than 2,000 procedures in more than 30 medical specialties."

Sunday, August 17, 2008

Often you can save yourself a long wait for the doctor at the clinic by getting advice on the telephone. Such a trend is becoming increasingly important today, when time is at a premium and commuting is so arduous, thanks to frequent traffic jams ! You need to learn to make intelligent use of the phone to get appropriate help from the doctor. However, when you're sick or hurt, it becomes difficult to think clearly and the following routine may help you to help the doctor give you the care you need over the telephone:

Keep a pen and paper ready so that you can write down the relevant instructions.

·Make sure all your medical records are at hand, so that you can answer questions about your medical problem intelligently and accurately.

Identify yourself properly, giving your full name as well as your diagnosis ( try not to tax your doctor's memory!).

Don't insist on talking only to the doctor every time you call. For example, if you just need to make an appointment, or merely clarify a doubt, the nursing staff or receptionist may be able to help you. To put it differently: respect your doctor's time!

When you don't know what you need (for example, you may not be sure how serious the illness is, i.e., if you require a visit to the clinic), tell the staff you're uncertain and request that you speak to a nurse or the doctor's assistant over the phone. Don't be hesitant; if you're feeling concerned or anxious, let the clinic staff know.

Ask if you can take a few minutes of the doctor's time now, or whether you should call back again - this is common courtesy!

Report specific symptoms. For example, rather than just saying, 'I don't feel well, or I've got the flu,' which can be interpreted in different ways, be prepared to describe your symptoms precisely; for instance, fever, sore throat, cough, and/or bodyache. Similarly, instead of just saying, 'my baby has a fever', specify the exact temperature and the duration of the fever as well as other signs or symptoms.

Don't misuse the phone by trying to wangle a free consultation. Not only is this unfair to the doctor, but also such a consultation is likely to be very unreliable!

·Ask the doctor what you should do and write down his instructions carefully. Ask the doctor to spell out any word if you are unsure about it.

Ask if and when you should call back, or if you should come to the clinic.

Ascertain what complications could occur that may require you to hurry to the emergency room.

Don't forget to thank the doctor for talking to you on the telephone!

If you have the doctor’s mobile number or residence number, please treat with respect. This is a privilege he has granted you, so don’t abuse it for routine calls which are better handled by calling the clinic or the secretary.

It’s a good idea to find out what the clinic policy is about phone calls in advance.

When is the best time to call?

What is the doctor's rule for returning calls?

Whom should you speak with (e.g., assistant, nurse) if the doctor can't come to the phone?

What is the phone number for making emergency calls or for calls when the office is closed?

Whom can you call if your doctor is out of town?

Sometimes, you may have to call a doctor after the clinic has been closed. Remember when you call a doctor after hours, he is trying to help you solve your immediate problem, not provide advice about your entire medical situation. Try to be specific in your complaint; you should know what medications you are currently taking and which of them has proved successful in the past. If you are not happy with the physician's advice or if you feel you are getting worse, go to the nearest emergency room at once.

Let me give an example of a precise and useful telephone call: 'I am an asthma patient and have had increasing wheezing today. I am not coughing up any mucus. I am using my albuterol inhaler every three hours but it doesn't seem to work. Last year when I suffered a similar episode, the doctor gave me prednisone and it worked, but the prescription is a year old. What should I do now?

On the contrary, here is an example of a bad telephone call: 'I don't feel good. The doctor treats me for breathing problem. I take three breathing pills, one is green, one is white and one is real, and I ran out of the red one last week. While I have you on the phone, I think I have a fungus on my feet, can you suggest a prescription for something for that as well….'

Making effective use of the telephone can help to save both you and your doctor considerable time, effort and money! Learn to use this instrument wisely and well.

Personally, I prefer email to talking to patients on the phone for many reasons.

1.Everything is documented

2.There is no scope for confusion or misunderstanding

3.I can refer to the patient’s medical records , to ensure my advise is correct

4.We don’t have to play telephone tag , which means I can answer at my own convenience. This is especially important for overseas patients, because of the timezone differences !

Smart patients need to learn how to communicate with their doctors – and using the phone and email effectively can help them they save the doctor’s time, as well as their own !

Practice Fusion fundamentally addresses these issue by offering no cost solutions that you can be up and running on in less than five minutes.

Lowest Total Cost of Ownership. Practice Fusion has eliminated the costs charged by traditional vendors' solutions, including licensing, hosting, maintenance and consulting fees. You have access to full technical support, complete video training, live web training, and the importing of all of your current patient demographics to get you started.

" Live in Five. " Forget everything you know about software. Practice Fusion's exclusive 'Live in Five' program allows you to be up and charting in less than five minutes. There are no sales contracts, no consultants to go on-site, no installation of hardware, software, and databases."

Many more doctors will be willing to use EMRs if this innovative model takes off ! I am very hopeful this will be the start of a new trend in doctors using software for intelligent practise management.

Friday, August 15, 2008

The Indian healthcare system has become sick. In the private sector, doctors are no longer held in high regard; the doctor-patient relationship has deteriorated; and patients believe that the medical profession has become commercialized. The dismal state of the government’s healthcare services for the poor and the middle-class has also been extensively documented. The knee-jerk reflex has been to train more doctors ; set up more hospitals; and force corporate hospitals and doctors to provide subsidised medical care. This is simply a form of " band-aid medicine". The only effective solution will be to rely on the one resource which is almost inexhaustible—the people themselves. The principle is simple – teach them so they can manage their own health problems.

The reason that India is shining today is that we are in a demographic “sweet spot.” India’s major strength is its middle-class, with its millions of educated young adults , and protecting their health should be a high priority. Unfortunately , healthcare remains a neglected area , because of which millions of working years ( and billions of rupees ) are wasted on preventable illnesses . Medical absenteeism exacts a huge toll , but because it is hidden from public view, we have not addressed this problem effectively.

This is a daunting task, and the challenges are enormous. However, the biggest mistake we make is to assume that people are incapable of tackling their own medical problems; and that we need to look to doctors for solutions. We need to change our focus. Instead of trying to provide sophisticated healthcare services ( blindly imported from the West) , which need expensive technology, fancy machines and highly trained specialists, we need to tap the people themselves. People are smart and motivated , and are capable of remaining healthy, if we give them the right tools and teach them how to use them.

Doctors are illness experts – and not healthcare experts. Healthcare needs to learn from the revolution which has occurred in microfinancing. When given money and the freedom to use it as they see fit , even very poor people have come up with remarkably innovative ideas which could never have been planned, designed or anticipated by the traditional experts - bankers!

Information Therapy - the right information at the right time for the right person - can be powerful medicine ! Ideally, every clinic , hospital, pharmacy and diagnostic center should have a patient education resource center, where people can find information on their health problem .

The key is to develop patient-friendly materials which people will want to watch and can learn from. Most of us are visual learners, so this should be in graphic format. Modern technology has made creating and sharing visuals easy, so each community can build its own customised health video libraries with ease ! A simple example would be to find an articulate doctor with excellent communication skills, and to record a doctor-patient consultation with her about the top ten common clinical problems. A library of such videos could then be published online as "open source content" ; and patients and doctors could download and dub these in local languages . This version can again be uploaded to the web and shared with other patients from all over the country. Web 2.0 technology empowers patients to form support groups and communities where expert patients can help others. As the technology improves, it will soon be possible to deliver this graphic educational content on the third screen which is quickly becoming universal - the cellphone. This means information will be available 24/7 , free of cost, whenever you need it ! Patients will make use of these videos, since they are in their own language; deal with their immediate personal concerns; use local characters they can identify with; and provide local solutions which they are familiar with .

Information Therapy enhances patient autonomy by putting patients first; promotes patient-centered healthcare; respects the fact that the patient is the expert on himself; emphasizes personal responsibility for health; reduces the risks of medical errors; improves patient compliance with therapy; reduces the risk of litigation, because the patient has realistic expectations of the treatment; empowers patients to make their own decisions; and allows the intelligent use of integrative medicine, ( such as yoga , homeopathy and ayurveda) , so people can explore what works best for them. It creates expert patients and allows patients and doctors to form a healthy partnership, by improving doctor-patient communication. Finally, it saves money on medical care , both by promoting self-care (thus encouraging patients to do as much for themselves as they can, and not become dependent on doctors) ; and helping them with veto power, so they can refuse medical care they don’t need, thus preventing overtesting and unnecessary surgery .

Is educating people about their health and medical issues too expensive ? In fact, it's too expensive not to do it ! Human capital is India's most precious resource and we cannot afford to squander it. Information Therapy is free ; has no side effects ; and provides a terrific return on investment. We should insist that doctors dispense information therapy every time they do a consultation; advise a lab test; or prescribe medicines. In fact, both the government and insurance companies can make prescribing information compulsory . Knowledge is power, and Information Therapy can be powerful medicine – let’s make the most of it !

This is an article I wrote for the Times of India I Believe supplement for the 15th of August - India's Independence Day.

Wednesday, August 13, 2008

This pamphlet has been produced thanks to my talented friend, Mrs Anjoo Chandiramani. Using google tools, it's now possible to create a library of health educational materials in Indian languages ! This is very exciting !

About MyDigitalHealth: "Imagine having the ability to take your health information and your lifestyle – turn them into a picture of your health now and your predicted health in the future. Imagine the ability to see how that picture changes based on changes in your lifestyle. And to use that information to create a health plan tailored to your lifestyle and health choices.This is the essence of MyDigitalHealth

MyDigitalHealth will synthesize your current health, your health history, and your lifestyle to generate a representation of you in a computer simulation of human physiology. You then can use this innovative personal health simulation to predict your future risk of disease and determine how that risk responds to changes in lifestyle, diet, or medication; and based on that, set a plan for yourself to try to reduce your risk and track your progress towards meeting your goals."

“Wanted: Caring professional with excellent communications skills, solid clinical judgment and honed technical abilities whom I can proudly call 'My Doctor.' You collect key medical and personal information and put the puzzle pieces together in a way that makes sense. You recognize that I am the expert on my own body, and offer insights that guide me to my choices that make most sense for me based on your knowledge and experience. When we don't see eye-to-eye, we respectfully agree to disagree. I deeply trust you. One day my life could be in your hands. you get the best, safest and most cost effective health care when you take your health into your own hands. Ask not what your doctor can do for you; ask what you can do with your doctor."

Health Care MVNO Prepares to Launch: "LifeComm is pursuing a market of 70 million baby boomers who are increasingly using medical resources. Qualcomm has said LifeComm wants to change traditional mobile phones into “in-the-hand” tools which can help boomers and others maintain good health or manage a medical condition. One aim of LifeComm will be to help individuals manage and treat chronic conditions such as diabetes, asthma and simple aging."

The purposes of this paper are: 1. to examine the strategies used by the world’s ruling class to keep the majority of humanity disempowered and complacent in the face of the crushing inequalities and hazards it engenders;2. to explore the methods and resources whereby enough people can become sufficiently awareand empowered to collectively transform our current unfair social order into one that is more equitable, compassionate, health-promoting, and sustainable."

Sunday, August 10, 2008

When most patients think of the internet, the first thing which pops into their mind is that they can use it to search for medical information. While it is true that this is still the commonest use of the internet today, the better news is that there are a lot of clever utilities on the internet which patients can use to get better medical care – and many of these are free.

The single most important medical application which is available on the internet now is the PHR – the Personal Health Record. This is available free at Times Wellness ( www.timeswellness.com) and the TimesWellness PHR allows you to store all your medical records ( including your CT scan images and lab results ) in one place. Because it’s online, it’s instantly available 24/7 – and can even be accessed through your mobile. This means that all your vital medical information is available to your family members in an emergency – or to you , even when you are travelling ! Keeping a PHR allows you to save money, and also helps you to improve the quality of your medical care, because it improves the communication between your doctor; your consultants and you ! With a PHR you will never lose old test reports ; or repeat tests unnecessarily, because your cardiologist does not know what your gastroenterologist is doing ! PHRs are especially useful for patients with chronic illnesses, such as hypertension and diabetes, as they allow you to record, track and graph your blood sugar levels and blood pressure ( BP ) levels over time – information which can be critically important in helping your doctor providing you with the right medical care ! You can try this out free at http://diabetescare.yoscare.in/.

The internet also makes talking to your doctor much easier ! Just like the telephone made house calls obsolete a generation ago, new internet technology ( such as telemedicine , video-chat and web-conferencing for eVisits ) can make a visit to the doctor’s clinic obsolete for many routine problems in a few years ! In fact, email has already become the preferred mode of communication for many progressive doctors, because it means they don’t have to play telephone tag with their patients; and ensures that all instructions are documented, so there’s less scope for confusion or misunderstanding. Cutting edge doctors in the US such as Dr Parkinson (http://www.jayparkinsonmd.com/) now manage their entire practice from their website. They do not have a clinic or an assistant; they allow patients to contact them through their website; and make house calls to treat patients. This is a great new model of personalized, high-touch , high-tech medicine called concierge medicine !

The good thing about the internet is it allows you to form online communities , which is what the Web 2.0 hype is all about. Being ill can be very depressing ; and causes social isolation, especially when you have a chronic illness such as multiple sclerosis, AIDS, infertility or cancer, because other “normal” people often do not understand what you are going through. Many websites allow patients to talk with each other so that they can share important medical tips; and provide emotional support as well. There are many Bulletin Boards and Forums, where patients with a particular disease can interact with each other; and where newbies can learn from “expert patients”.

In recent years, “ E-patients “ have become even more active because new web tools ( such as blogs and wikis ) have made online publishing and sharing of content so easy. They help each other in their time of need. If you need help and support, you can publish your own care pages free online at websites such as http://www.carepages.com/ and www.careflash.com !

Some websites such as www.patientslikeme.com have gone one step further. They allow patients to upload their medical details online, so that this information can be collated, analysed and used for research.

All health insurance companies in the US have their own websites. Not only do these provide valuable information to help clients remain healthy; they also help to reduce the company’s transaction costs, by allowing customers to fill in forms online. It’s also possible to buy health insurance policies online now ! It’s just a matter of time until Indian companies catch up.

Many pharmacies sell medicines online . Not only does this save you a trip to the chemist; it often saves you considerable money, as you can buy inexpensive generics; or shop for the best deal.

Smart US companies such as MyMedLab ( http://www.mymedlab.com) allow patients to order their own lab tests online ! You still need to go to the lab to get your blood sample drawn – but you save on the doctor’s fees !

As the web becomes ubiquitous, and as mobile phones become smarter, many health applications will be available on the mobile. The mobile will act as an extension of your doctor, and will be used extensively to help you remain well – for example, to help you manage your diet; motivate you to exercise; or to lose weight. And what of the future ? It may actually be possible to implant health sensors which will upload readings to a central monitoring station through the web – allowing better management of chronic diseases, such as hypertension and diabetes !

I have started work on an exciting new project. We are converting our book, How to Have a Baby into a comic book format. While many people enjoy reading books, it's also a fact that books without pictures are very boring - and that it's possible to transmit much more information in an entertaining format using the comic book approach.

Am working with a very talented artist to deliver this and this s the first draft of the chapter on hirsutism. Feedback and comments are welcome - we hope to use these to improve the comic book !

The recent debate about whether couples should be allowed to abort a fetus who has a birth defect after the 20 week legal limit has been featured exhaustively in the Indian press. This is one of those topics which generates more heat than light ; and since it provokes strong emotions, we often lose sight of logic while looking at these controversial issues. Doctors and philosophers have evolved systems to deal with such sticky issues – and this is the domain of medical ethics.

What is medical ethics, and how does it apply to you ? Doctors have always been responsible professionals and they deal with life and death on a daily basis. We realize that every patient is different ; many areas are highly controversial; and that there are no easy answers for many medical problems. These include: when does life begin ? should abortions be allowed ? till what age is it permissible to abort a fetus ? is cloing ethical ? should we permit euthanasia ( mercy-killing) ? when is it allright to remove life-support from a patient ? These are complex areas because they deal with medicine, religion , morality and law.

The medical profession has always abided by a code of ethics. This was first formalized by Hippocrates over 2000 years ago as the Hippocratic oath. Modern updated versions include the Indian Medical Council’s Ethical Code for doctors.

The three pillars of medical ethics are:

Autonomy ( independence). We respect the patient’s autonomy, and empower him to decide . The patient should have the final say, and has the right to refuse or choose their treatment.

Beneficence. The doctor should act in the best interest of the patient. This is the hallmark ofany professional.

Non-maleficence. "First, do no harm" (primum non nocere). The action should not harm anyone.

These pillars do not always give pat answers as to how to handle a particular situation, but do provide a useful framework for understanding and resolving ethical dilemmas. Sometimes, no good solution to a dilemma exists, and occasionally, the values of the patient or doctor conflict with the values of society.

How can we apply these principles to a particular case ? For example, should abortions be allowed after 20 weeks when the fetus has a severe birth defect ? Is it permissible to kill the fetus because the parents want to ? Some actions can create a positive outcome while also potentially doing harm. How do we balance these ?

The principle of non-maleficence states that no one should be harmed. Allowing the abortion will harm the fetus because it will take away its life. This brings us to the thorny issue of when the fetus can be considered to be a independent human being . Normally, the answer would be only after birth – but is it fair to use different standards because the baby has not yet been born ? Many religions ( and pro-lifers) would condemn all abortions, no matter what the age of the fetus, because they think it is reprehensible to take away life when we do not have the power to create it. They feel this is like playing God – and if we are willing to kill a fetus at 20 weeks, then what’s to stop us from killing it at 28 weeks ? or at birth ? On the other hand, is it fair to burden the parents with the responsibility of bringing up a child with a birth defect, when they don’t want to do so ? We need to realize that the 20 week limit is arbitrary – and just because it is laid down in a law does not give it a special status ! The fact that different countries have different limits (even though humans are the same all over the world) just underlines this arbitrariness !

Unfortunately, laws are rigid, because they are in black and white. The problem with this is that they cannot keep up with changing medical technology. Thus, while a law passed in 1971 was a great law at that time, it may no longer begood in 2008. However, amending a law is a challenging and expensive options. In order to prevent such problems, all laws which deal with health and medical issues should have some flexibility built into them, to provide them with a human face. For example, they could have a clause which allows an empowered committee of doctors, officials and judges, to consider individual cases who have special needs. Until this happens, the law will continue causing a lot of private pain, because it is blind.

There are no easy answers – and only King Solomon could resolve disputes like this without offending someone. Each individual will look at this issue with a different lens. Personally, I find that the principle of autonomy is very useful in resolving such cases.

The principle of autonomy recognizes the rights of individuals to self determination. This is rooted in our democratic society’s respect for citizens’ ability to make informed decisions about personal matters. If the goal of family planning is to ensure that every child is a wanted child, then is it fair for Society to force couples to have a child they don’t want ? Who is this good for ? It seems to harm everyone involved – the parents, because they don’t want the child; the child, because it is unwanted; and society as well, because it is then burdened with an unloved child.

I think how we look at this depends to a large extent on our world view. Most judges spend all their time resolving disputes between individuals and giving judgments. They naturally take the view that individuals cannot resolve matters for themselves or make sensible decisions. ( If they could, then they would never need to come to the Court for justice !) Because they are used to dispensing justice, they are very comfortable deciding and interpreting for others. Doctors, on the other hand, are much more likely to be empathetic, because they are in a “helping profession” and are more tuned to helping patients attain their own goals. They will often follow the Golden Rule -treat others the way you would like to be treated yourself !

Life was much simpler in the past. Society allowed doctors the freedom to help patients make these decisions on medical matters of life and death ; and trusted that doctors would fulfill the trust placed in them because of their professional code of ethics. Patients who had a problem would go their personal doctor, who would use his judgment in crafting a solution suited to their personal circumstances.

Unfortunately, today the medical profession in India is in crisis and society no longer holds the medical profession in the high esteem it used to in the past. Doctors are no longer felt to be trustworthy – and their ability to make decisions in their patients’ best interests has been progressively curtailed. These decisions are now made by bureaucrats and judges , who often may not feel the individual pain of the patient, as they do not see patients one-on-one. This lack of empathy means that most decisions are made using only facts, figures and logic – as a result of which they are often cruel to individuals. This is hardly surprising, because decisions made by a system are designed to be heartless – and this is the price we have all agreed to pay.

Friday, August 08, 2008

Dim economy drives women to donate eggs for profit - CNN.com: "With a full load of classes, two young children and her bills piling up, Michelle decided to face her economic straits in a pretty unorthodox way.As the nation's economy is slumping, some fertility clinics say interest in donating has surged.

She is donating her eggs to an infertile couple.

'The cost of living is crazy right now, with two kids, gas prices and rent. ... I'm living paycheck to paycheck,' said the 24-year-old, who did not give her last name to protect her identity. 'I just really need the money to finish school.'

Michelle is not alone. As the nation's economy is slumping, some fertility clinics say interest in donating has surged."

When women in the US donate eggs, it's considered to be an innovative way of making ends meet. When poor Indian women do exactly the same thing, doctors are accused of exploiting them !

Thursday, August 07, 2008

Baby born to surrogate Indian mother in legal limbo - Yahoo! News: "The future of a 12-day-old baby girl born to an Indian surrogate mother hung in legal limbo Wednesday after the Japanese couple who planned to take her home divorced. Manji Yamada was born last month after eggs from an Indian donor were fertilised using the Japanese man's sperm and implanted in the womb of the surrogate Indian mother.

Her biological father split from his wife after the fertilisation process, and his former spouse no longer wants the baby. In the absence of a surrogacy law in India, the child -- who is an Indian citizen -- will have to be adopted by her Japanese father Ikufumi Yamada, 45.

But Indian law does not allow the adoption of a girl by a single father, lawyers and doctors said."

This is a real-life example of one of my worst fears coming true.

How can any one adopt a baby without going through an adoption agency process, which can take 2-3 years ?

With the increasing numbers of infertile couples coming to India for surrogacy treatment, this problem is likely to escalate, because birth certificates to these babies are being issued illegally and fraudulently. Infertility clinics are taking advantage of the desperation of these couples and using the garb of " ICMR guidelines" to issue false birth certificates.

Hopefully , the passage of a law to regulate surrogacy will improve matters, provided the law is drafted well. I have made some suggestions in an earlier post, as to how this can be done in a way which protects everyone - the infertile couple; the doctor; and the surrogate.

Wednesday, August 06, 2008

In the clinic of the Malpani, one of the favorites for foreigners, in vitro fertilization process is the most requested.La novedad es que cada vez implantan más embriones de dos indios o producto del semen o de óvulo indio en madres extranjeras. The novelty is that ever more embryos implanted two Indian product or semen or ovum in Indian foreign mothers.En los últimos años, las parejas que acuden a su centro han dado a luz a bebés interraciales. In recent years, couples who come to his center have given birth to babies interracial."Pedí al doctor que me eligiera una india donante de óvulo guapa y de piel clara para que no hiciera tanto contraste, porque mi marido y yo somos blancos", cuenta por teléfono Paulette Cordoni, una estadounidense de ascendencia alemana. "I asked the doctor that I chose a donor egg india beautiful and skinned so they do not make much contrast, because my husband and I are white," says Paulette Cordonier by telephone, an American of German descent.Vincenzo, su hijo de 21 meses, se parece al padre. Vincenzo, his son 21 months, looks like the father.

Raekha Prasad on fertility tourists to India | Life and style | The Guardian: "At the end of last year, Ekaterina Aleksandrova boarded a plane in London and flew to Mumbai. It wasn't her first trip there - she is a management consultant and often goes abroad on business. But this time she went to have five embryos implanted in her womb. A couple of days later she flew back to Europe. While on business in Hong Kong in January, she discovered she was pregnant with just one embryo.

For Aleksandrova, 42, this was the culmination of a six-year struggle to become a mother. She divorced at 29, and hadn't been in a serious relationship since she was 34. 'I always wanted to have a child but the men kept saying, 'Why don't we travel?'' she says. 'It wasn't that I was obsessed with my career, I just couldn't get men to be a father.'

First, she tried to adopt in Germany, where she holds citizenship, but that didn't work out. Then, in 2004, she moved to the UK to take advantage of this country's more liberal attitude to single women who need IVF. She spent £18,000 in less than three years, trying and failing to conceive at a private Harley Street clinic. When she finally conceived in India, Aleksandrova was in a state of 'shock and disbelief'."

What can America do about it? Panelists suggested eliminating one primary villain-the fee-for-service approach-in favor of the medical home or other new models that offer coordinated care and continuity of providers. This new paradigm opens the door to a patient-provider relationship marked by a two-way sense of responsibility.

Everyone recognized the potential barriers to implementation: Peggy O'Kane offered a 'multi-stakeholder approach' as an antidote to the stifling influence of interest groups; while Tim Jost suggested that regulatory waivers will be essential to clearing the way for innovation.

Other challenges brought to the table include: creating incentives for engaging patients in their own health, developing a nationwide system of health care IT, and insuring that new programs dovetail into the larger system of acute and preventative care."

Sunday, August 03, 2008

Learning to talk to patients is a basic skill all doctors need to master. While the mechanics are well described in most textbooks ( for example, sit down and talk to the patient; show empathy; check for understanding) and most doctors learn this well , what takes a lifetime to master is what not to tell !

Most junior doctors will make it a point to tell everything. This is what they have been taught to do - and they are quite good at regurgitating facts. Unfortunately, they often overload the patient with information, much of which is irrelevant, as a result of which the patient gets lost in the trees and cannot see the forest.

More senior doctors learn to edit the information they provide. Not only do they know what to tell; they also know when to tell this; to whom - and how much. Often, information is provided in titrated doses, so that patients have a much better picture of what their options are.

This powerful skill is a key component of a good bedside manner and can take years to master. While good doctors will use this skill for the patient's good, unfortunately, some will misuse this to slant the information they offer; or censor some of it.

Since it's impossible for an outsider to judge the intentions of a doctor, most lawyers advise doctors to just tell the entire truth . While this is easy to do , the fact is that sometimes this is not in the patient's best interests ! Good doctors know this - and are masters at communicating bad news. If you have such a doctor, treasure him !

Stories are a great way of communicating - and we think stories told by patients carry a lot of weight.

Here's an IVF success story from one of our patients.

" We are a couple from Atlanta, Georgia . Just like most of us, we had a hard time conceiving for many years. By twist of fate we happened to be in India and have been introduced to Malpani clinic. My husband travels a lot for his job and for the last several years he comes to India often. I join my husband most of the time on his business trips, and that is how we ended up in Bombay, India.

I first came across Malpani clinic’s website a few years ago but I did not even think about doing the treatments in India, it was more like a curiosity. Well, a few years later we were staying in Bombay again and I received an e-mail from my friend from home with the same Malpani clinic’s website. Since I was already in India and not too far from this clinic I talked to my husband and we decided to “check it out”. Trust me, we had many concerns before we sat up that appointment. My husband is an engineer and his main concern was that clinics in India do not have the appropriate equipment to carry out such a procedure. This is why the first thing that my husband asked when we met with Dr. Malpani is to show all of the equipment that will be used. I can honestly say just one thing; my husband and I were satisfied with what we saw. All of the equipment came from Japan and was the best available. So, after we met with doctors Malpani and talked to them, we decided to start a treatment right away.

I had all my tests done in Atlanta earlier, so I did not have to repeat them again. My husband, on another hand, being a member of the famous Kaiser Permanente HMO had done 4 sperm tests and never saw a doctor or even the results of his tests. So much for the “great” American medical system…. Dr. Malpani needed just one sample from my husband and after 5 min. he told us the results, he actually showed it to us on computer screen and explained why we need this particular treatment.

The whole treatment procedure lasted for about three weeks. The first two weeks I was receiving hormonal injections to stimulate my egg production. In my case, my husband did all the injections himself, so we did not have to see the doctor every single day. I was required to see the doctor thought to check how the eggs are developing a few times during my injection therapy. After two weeks when my eggs were fully developed, they were removed under the general anesthesia and embryos were put back inside in a day. I was really scared about the surgical procedures but I had no problems at all. I had no pain, no blood, unbelievably for my self, I was just fine. I and my husband saw our embryos on a computer screen before we decided how many of them we want to put inside of me. Doctors Malpani explained to us why these particular embryos are the best and we even took a picture of them for our family album.

My main advantage of doing this treatment away from home was the requirement for time and an ability to relax. You know how we all are usually busy at home. Even if we do not work, there is always something hectic going on. Another great reason to do this procedure in India is the cost. The total price we paid for the whole treatment is about 20% of what it would cost in America. By the way, all of the medicine that was provided by Dr. Malpani for this treatment is made in Germany and France and the cost for this medicine in India is much lower then in America. More that that, the cost of this medicine in America would be more than the entire treatment cost us in India. So, this trip to India might be beneficial in many different areas at the same time. You can conceive a baby, forget about your daily routine and relax, look at the country and learn about its culture. The important thing is to come to India at the right season. One should avoid months of April – September because these are the hot and rainy months. The winter in Bombay is very nice with mild days and cool nights.

I got pregnant after the first try and I am now 8 weeks pregnant. Now it’s up to me and my body to make sure this pregnancy will go to term, but I know for sure that great doctors Malpani did everything that they could to make it happened. Did you check the statistic of IVF clinics in America? Their success rate is not better than 30%. Did you check the number of treatments that they do? Did you check the number treatments per doctor? Well, small Malpani clinic in India is a very very busy clinic. You can meet people there from different parts of the world. Now I know that there is a reason why all these people travel half way across the world to Malpani clinic. This husband and wife practice probably carried out more IVF treatments than a large hospital in USA. Their experience and dedication attract a large number of future parents who need help just like us.

Today's Times of India has a great article on a couple from Israel who came to India for surrogacy treatment. They transferred their frozen embryos into a surrogate and have taken their baby back with them to Israel.

While this is a very good example of how resourceful infertile couples can be, what worries me is the fact that there is no mention made of how the baby was taken out of the country. Presumably, the passport was issued on the baby's name, based on the birth certificate. Now, while surrogacy is legal in India, Indian law dictates that the name on the baby's birth certificate has to be the birth mother's. The father's name will be the name of her spouse . A birth certificate is a legal document and cannot be fudged or changed, no matter who the genetic parents are. Clinics use the garb of the "ICMR guidelines" to justify putting the name of the intended parents on the birth certificate. While the intention may be good, I am not comfortable about the fact that the law is being bent to suit a patient's convenience. This is a grey-area which needs to be urgently addressed. Otherwise, we may create loopholes which could be exploited by unscrupulous people to short cut the legal adoption process by putting the wrong name on the birth certificate, in case a couple wants to adopt an unwanted baby, without having to wait the 3 years it takes now through the legal adoption process.

The company will pilot telemedicine through retail clinics in Houston, and will be trademarked as Walk-In Telemedicine Health Care. Wal-Mart will be partnering with My Healthy Access and NuPhysicia, the private company that comes out of the long-successful telemedicine program at the University of Texas Medical Branch at Galveston. Telemedicine was been pioneered at U-T in Galveston over the past 10 years, and the program has global reach.

Instead of employing nurse practitioners, the medical model for this program will use paramedics working under the supervision of physicians via various scopes technologies -- electronic stethoscopes and beyond. NuPhysicia describes this process as, 'interactive physician visits.'"

The number of people heading abroad for ``medical tourism'' could jump tenfold in the next decade, to nearly 16 million Americans a year seeking cheaper knee and hip replacements, nose jobs, prostate and shoulder surgery, and even heart bypasses, according to a forecast by health care consultants at the Deloitte Center for Health Solutions."